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Ever Have a ‘Situation’ with YOUR Health Insurance Company?????

In life, many things are not as you would think. The signs may point to one thing, but once you are ‘through the gate’ you find that it is something else altogether.

I am contacted a lot about insurance companies. What is covered, what is not covered. Why are they so difficult to speak to? Why don’t they cover everything? Why did they used to cover XYZ and now they only cover ABC? Let’s get together and ‘get’ the insurance companies to do THIS or THAT; who is with me?

Uhmmmmmmmm………wait………no.

The first thing you must understand about insurance companies is that they are a business. Business has one objective at the top of their pyramid….to make money. Make money for themselves, make money for their stock holders, whatever. I learned a valuable lesson a long time ago. There was a woman who worked part-time. Her company only covered full-time employees. When she inquired as to why they did not allow part timers to ‘buy in’ to the full timers policy, she was told it was not an option. The why, she later found out, was the ones asking for it—are the ones who wanted it—for a reason. Why would an insurance company encourage a liability on their dockets if they do not need to?

Some people believe that insurance companies are a service organization, they are not. That is not a bad thing, but it’s something you need to realize and understand.

If you have a child with T1 diabetes (or any chronic disease) on your insurance, the insurance company automatically knows they will probably lose money on your family. THAT is not a good thing for them. Because of all sorts of rules, laws, and regulations, insurance companies have to add you if the rest of the employees are being covered. They will learn pretty quickly that you are not one that they will earn a profit.

Now look at this differently. If there are two million people with T1 diabetes, insurance companies need to work for less damage to their bottom line. They know they must pay out to cover you. But let’s say they pay less for you and you have to shell out an additional $100 a year from you, and they save $100 per person by other means—–they just saved 400 million dollars. Get it?

It’s a numbers game.

So when you call them, you have to know in your mind that they will be doing something to save money. It’s your job to know what your insurance covers and how to ‘counter’ when they push-back on something you need. Know the process to appeal any decision that you know is needed. Know that ‘X’ which is a different brand name from your ‘Y’ may be something you need to live with if you want it covered by your insurance.

I’m not sure if this is a way to wear you down, but the more amount of steps you need to rectify something, or the more amount of calls you have to make, or the more amount of paperwork you have…….the more likely you will ‘give-in’ and just do it any way that is easiest………..my advice on that………………don’t. I never speak to someone who has to go to someone else for an answer. Ask for a supervisor. Ask what can you do to change the ‘no’ into a ‘yes’.

‘Let me see’, or ‘let me check’, or ‘maybe’ are all phrases you want to hear……you do not go from a ‘no’ to a ‘yes’ without passing through one of these phrases. Also know there is no such thing as a quick call to the insurance company. Call when you have a good deal of time to spend to solve the problem. Take down notes; who you spoke to, the date, the time and what was said. And NEVER hang up until you ask; “Who should I speak to next to help me resolve this?” If they say they don’t know, ask to speak to someone else there in a supervisory position who can advise you where to go next. DO NOT LET THEM OFF THE HOOK.

The other thing about being a business is that they want customers satisfied. There is a difference between strong and rude; inquisitive and challenging; and making them your partner to achieve a correct solution………but know how it is all played out. Also know that the answer may indeed be a ‘no’. If you exhaust every avenue, appeal, and inquiry—know that what you are asking is JUST NOT possible.

But always be willing to give it a good and educated shot. So although things may not always be as they seem, we also do not have to merely accept the answer without a good and detailed discussion on doing what is right for your family. Our best insurance, is our willingness to ‘work the system’. The best way to know that, is to do it.

2 thoughts on “Ever Have a ‘Situation’ with YOUR Health Insurance Company?????”

Also, If they are denying you something that you know you’re supposed to be able to get, and you’ve gone through the initial appeal, you still have 2 options: go directly to the CEO’s office. It can be tough to find the number, but every CEO has an Executive Complaint Group that can cut through red tape quickly. The second is to hire healthcare advocate, like Healthcare Navigation. They will deal with the approvals, bills, etc, and do it very quickly. The cost is offset by the tremendous savings that they can get for you.

My only issue with the insurance we have is that they consider a continuous glucose monitor such as the Dexcom 4 to be “durable goods”. The insurance company defines a durable good as something expected to last a minimum of three years. The insurance company does not cover the Dexcom 4 because Dexcom does not “guarantee” it will last the three years. Out of pocket is out of the question given our income so we are out of luck, for now.